Odin Health And Rehab Center

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

49.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 110 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 44.1% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 34 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.26 therapist hours per resident per day in 2026Q1 — more than 37% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 4% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 99 beds and averages 67.6 residents a day — about 68% occupied, or roughly 31 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.02 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.31 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.99 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.29 hrs/resident/day on weekends vs 3.32 on weekdays — 31% thinner on weekends — a notable drop. RN hours go from 0.39 to 0.10 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 61% is well above the national median of 45%. 3 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

53 citations, most serious first. The 22 most serious are shown; the remaining 31 are one tap away and print in full.

• Immediate jeopardy · Jcited before2025-11-14 · tag F0580 — failed to tell family and doctor about changes — isolated
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to notify the physician for a resident's change in condition for 1 of 3 residents (R1) reviewed for changes in condition in a sample of 13. This failure resulted in R1's hospitalization for sepsis and subsequent death.This failure resulted in an Immediate Jeopardy, which was identified to have begun on 10/5/25 when the facility staff failed to notify the physician that R1 had decreased urine output and oral intake, was refusing to eat, and appeared lethargic. On 10/7/25, R1 was found to have a worsened pressure ulcer and a sharp decline in R1's overall condition and was sent to the ER (Emergency Room). R1 expired on 10/8/25 with a cause of death of Sepsis. The findings include: R1's Face Sheet documented an admission Date of 3/3/22 and listed Diagnoses including Asthma, Peripheral Vascular Disease, Hypothyroidism, Bipolar Disorder, Hypertension, and Diabetes Type 2. R1's Minimum Data Set, dated [DATE] documented that R1 was severely cognitively impaired,…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2024-05-15 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents were free from sexual abuse for 3 of 3 (R2, R9, R11) residents reviewed for abuse in the sample of 34. This failure occurred on [DATE] when V4 (Physician/Co-Medical Director) asked to see and touch R9's genitalia (inappropriate word for female genitalia), while R9 was sitting in the lobby of the facility near the front doors. R9 stated this had been going on for a few months, she would get upset by V4's behavior, her anxiety would rise before he was scheduled to visit, and she began wondering if she had said something to initiate this behavior and began blaming herself. R9 stated she was afraid to tell anyone because it would be her word against his and no one would believe her. The Immediate Jeopardy began on [DATE] when V4 was witnessed by this surveyor making inappropriate sexual comments to R9. V1 (Administrator), V53 (Chief Clinical Officer), and V54 (Resident Services-Corporate) were notified of the Immediate…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2024-05-15 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents assessed as being a high risk for elopement were adequately supervised and then failed to identify this same resident as an elopement risk after an elopement for 1 of 3 (R1) residents reviewed for accidents and supervision in the sample of 34. This failure resulted in R1, who had a history of confusion and was assessed as being a high risk for elopement, exiting the facility without staff knowledge, at an unknown time, walking 4.4 miles to a neighboring town along a busy highway where he was located by facility staff at 7:00 AM on 4/13/24. The Immediate Jeopardy began on 4/13/24 when R1 exited the facility without staff knowledge. R1 walked approximately 4.4 miles and was found by facility staff at 7:00 AM on 4/13/24. V1 (Administrator) was notified of the Immediate Jeopardy on 4/29/24 at 1:57 PM. The surveyors confirmed by observations, interview, and record review that the Immediate Jeopardy was removed on 4/13/24, but…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2024-05-15 · tag F0760 — failed to prevent significant medication errors — isolated
  Ensure that residents are free from significant medication errors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were free of significant medication errors for 3 (R23, R10, R27) of 13 residents reviewed for medication errors in the sample of 34. This resulted in R23 experiencing a blood glucose level of 37, altered mental status and being transported by EMS (Emergency Medical Services) to the Emergency Department for evaluation and treatment. Additionally, this failure resulted in R27 experiencing anxiety and an increase in behavioral symptoms, requiring an inpatient psychiatric hospitalization. The immediate Jeopardy began on 4/9/24 when insulin was administered to R23 without first performing a blood glucose check as ordered. V53 (Chief Clinical Officer) and V66 (Regional Operations Clinical Consultant) were notified of the Immediate Jeopardy on 5/8/24 at 2:40 PM. The surveyors confirmed by observations, interview, and record review that the Immediate Jeopardy was removed on 5/8/24 but noncompliance remains at Level Two due to additional time…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2024-04-02 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents with psychiatric diagnoses, who were at risk of elopement, were accurately assessed and appropriately supervised for 1 of 3 (R2) residents reviewed for accidents and supervision in the sample of 17. This failure resulted in R2, who has a diagnosis of schizoaffective disorder and a history of suicidal ideation's exiting the facility without staff knowledge on [DATE] sometime between 4:45 AM and 5:30 AM. R2 was located slightly more than two tenths of a mile from the facility at approximately 6:30 AM, sitting outside an abandoned building on top of a truck camper shell, in the rain. R2 had to cross a busy highway to get to this location. This failure resulted in an Immediate Jeopardy, which was identified to have begun on [DATE] when R2 exited the facility with out staff knowledge. R2 walked approximately two tenths of a mile and was found by staff approximately one hour later. This past noncompliance occurred from [DATE] to [DATE]. V1…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Actual harm · G2025-11-14 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to recognize and assess the symptoms of a worsened pressure wound and provide and document wound treatments as ordered for 2 of 3 residents (R1, R3) reviewed for pressure ulcers in the sample of 13. This failure resulted in R1's sacral ulcer worsening and R1 being transferred to the hospital, where the wound was found to be infected with gram positive cocci and gram-negative bacilli.The findings include:1. R1's Face Sheet documented an admission Date of 3/3/22 and listed Diagnoses including Asthma, Peripheral Vascular Disease, Hypothyroidism, Bipolar Disorder, Hypertension, and Diabetes Type 2. R1's Minimum Data Set, dated [DATE] documented that R1 was severely cognitively impaired, had an indwelling catheter, and was totally dependent on staff for eating, showering, toileting, and transfers. An October 2025 Wound Log documented that R1 had a stage 4 pressure wound to the sacrum and a stage 4 pressure area to the right heel. R1's Care Plan…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-08-06 · tag F0697 — failed to manage pain — isolated
  Provide safe, appropriate pain management for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide narcotic pain medication per physician orders for 2 of 3 (R1 and R3) residents reviewed for pain management in a sample of 3. This failure resulted in R1 and R3 experiencing unrelieved pain and having to be sent to the local hospital for treatment of pain. This past noncompliance occurred from [DATE] to [DATE].The findings include:1. R1's admission Record dated [DATE], documents an admission date of [DATE] with diagnoses in part of displaced comminuted fracture of shaft of humerus to right arm, multiple fractures ribs right side, unspecified fracture of unspecified lumbar vertebra, chronic migraine, and other chronic pain.R1's MDS (Minimum Data Set) dated [DATE], documents in Section C a BIMS (Brief Interview for Mental Status) score of 15 which indicates R1 is cognitively intact.R1's Care Plan with a date initiated of [DATE] has a focus area of R1 (Resident) has potential for pain from trauma/injuries received prior to admission. Interventions…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Actual harm · Gcited before2025-07-11 · tag F0697 — failed to manage pain — isolated
  Provide safe, appropriate pain management for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide narcotic pain medications per physician's orders for 1 (R1) of 3 residents reviewed for pain management in the sample of 5. This failure resulted in R1 experiencing unrelieved pain and having to be sent to the local hospital for treatment of pain. R1's admission Record documents that R1 is a [AGE] year-old that was admitted to the facility on [DATE]. Diagnoses included are unspecified fracture of right femur, cirrhosis of liver, pain due to internal orthopedic prosthetic device, pain in right hip, weakness, chronic kidney disease, anemia, and osteoarthritis of right knee. R1's MDS (Minimum Data Set) dated 06/16/2025, documented that R1 has a BIMS (Brief Interview for Mental Status) score of 15 indicating R1 is cognitively intact. R1's Care Plan with a revision date of 09/30/2024 has a focus are of The resident has chronic pain. Interventions listed are administer analgesia as per orders, anticipate the resident's need for pain relief and…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-07-11 · tag F0760 — failed to prevent significant medication errors — isolated
  Ensure that residents are free from significant medication errors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure resident received the correct medications in accordance with their physician's orders for 1 (R4) of 3 residents reviewed for medications in the sample of 5. This failure resulted in R4 having increased behaviors and being hospitalized for behaviors. R4's admission Record documents that R4 was admitted to the facility on [DATE]. Diagnoses listed are vascular dementia, type 2 diabetes mellitus, brief psychotic disorder, unspecified mood disorder, auditory hallucinations, schizophrenia, anxiety and unspecified psychosis.R4's MDS (Minimum Data Set) dated 03/26/2025, documents R4 has a BIMS (Brief Interview for Mental Status) score of 15, indicating R4 is cognitively intact.R4's Care Plan with a revision date of 5/7/24 documents a Focus area of This resident is on an antipsychotic. Documented interventions include: Administer medication as directed by physician. R4's Order Listing Report dated 07/10/2025 documented an order for Haloperidol Decanoate…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-03-28 · tag F0697 — failed to manage pain — isolated
  Provide safe, appropriate pain management for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to provide narcotic pain medications per physicians orders and failed to assess the effectiveness of non narcotic pain medication for 2 of 2 residents (R1, R3) reviewed for pain management in the sample of 14. This failure lead to R1 and R3 experiencing unrelieved pain up to 9 and 10 on a scale of zero to ten. Findings include: 1. R1's Face Sheet documented an admission Date of 9/20/23 and listed Diagnoses including Bipolar Disorder, Chronic Obstructive Pulmonary Disease, and Morbid Obesity with a Body Mass Index of Greater than 70. A Minimum Data Set, dated [DATE] documented that R1 has minimal deficits in cognition. R1's Care Plan dated 3/17/25 documented a problem area, The resident displays manipulative behavior related to a psychiatric disorder, with corresponding intervention,Educate resident on appropriate means of requesting help for self or others. The Care Plan also documented a problem area, The resident is on pain medication therapy, with…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2024-04-02 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
  Provide safe and appropriate respiratory care for a resident when needed.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure staff were trained and the facility had the necessary equipment to meet the needs of a resident with a tracheostomy for 1 of 1 resident (R3) reviewed for tracheostomy care in the sample of 17. This failure resulted in R3 becoming short of breath shortly after admission with the facility unable to locate the necessary equipment to provide oxygen to R3 via the tracheostomy, causing R3 to be anxious and scared and then being transferred to the local hospital for oxygenation. Findings Include: R3's admission Record with a print date of 3/21/24 documents R3 was admitted to the facility on [DATE] with diagnoses that include local infection due to central venous catheter, bacteremia, asthma, malignant neoplasm base of tongue, malignant neoplasm of larynx, tracheostomy, heart failure, depression, anxiety, hypertension, and atrial fibrillation. R3 is in the assessment period so her MDS (Minimum Data Set) did not document a Brief Interview…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-09-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to safely transport a resident in a wheelchair to prevent an accident for 1 of 3 residents (R3) reviewed for accidents in the sample of 3. This failure resulted in R3 sustaining a fall from R3's wheelchair that resulted in a laceration to the bridge of the nose, requiring treatment of glue to the nose at the local hospital emergency room. This past non-compliance occurred between 9/16/23 and 9/22/23. Findings include: R3's undated admission Record documents that R3's initial admission date to the facility was 12/01/19, with current admission date of 01/03/20. R3's diagnoses listed on this document include, but are not limited to Chronic Obstructive Pulmonary Disease, Morbid (Severe) Obesity Due to Excess Calories, Atherosclerosis of Native Coronary Artery of Transplanted Heart Without Angina Pectoris, Generalized Anxiety Disorder, Dementia in Other Diseases Classified Elsewhere, Unspecified Severity, Parkinson's Disease, Cognitive Communication Deficit,…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Potential for harm · Dcited before2025-08-06 · tag F0755 — failed to provide safe pharmacy services — isolated
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to obtain a new prescription for a controlled substance in a timely manner for 2 of 3 residents (R1 and R3) reviewed for pharmacy services in the sample of 3. This past noncompliance occurred from [DATE] to [DATE].The findings include:1. R1's admission Record dated [DATE], documents an admission date of [DATE] with diagnoses in part of displaced comminuted fracture of shaft of humerus to right arm, multiple fractures ribs right side, unspecified fracture of unspecified lumbar vertebra, chronic migraine, and other chronic pain.R1's MDS (Minimum Data Set) dated [DATE], documents in Section C a BIMS (Brief Interview for Mental Status) score of 15 which indicates R1 is cognitively intact.R1's Care Plan with a date initiated of [DATE] has a focus area of R1 (Resident) has potential for pain from trauma/injuries received prior to admission. Interventions listed are administer medication per physician order(s) and monitor for side effects and effectiveness.…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Past Non-Compliance
• Potential for harm · Dcited before2025-07-11 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were free from physical abuse for 1 (R4) of 3 residents reviewed for abuse in the sample of 5. R4's admission Record documents that R4 was admitted to the facility on [DATE]. Diagnoses listed are vascular dementia, type 2 diabetes mellitus, brief psychotic disorder, unspecified mood disorder, auditory hallucinations, schizophrenia, anxiety and unspecified psychosis. R4's MDS (Minimum Data Set) dated 03/26/2025, documents R4 has a BIMS (Brief Interview for Mental Status) score of 15, indicating R4 is cognitively intact. R4's Care Plan with a revision date of 07/08/2025 has a focus are of, (R4) is at risk for decline in psychosocial well being related to: Allegation of abuse related to a resident-to-resident altercation. The interventions listed are: provide 1:1 visit, and staff educated to keep residents separated. R5's admission Record documents that R5 was admitted to the facility on [DATE]. Diagnoses listed are acute respiratory…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-07-11 · tag F0755 — failed to provide safe pharmacy services — isolated
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to obtain a new prescription for a controlled substance in a timely manner for 1 of 3 residents (R1) reviewed for pharmacy services in the sample of 5.R1's admission Record documents that R1 is a [AGE] year-old that was admitted to the facility on [DATE]. Diagnoses included are unspecified fracture of right femur, cirrhosis of liver, pain die to internal orthopedic prosthetic device, pain in right hip, weakness, chronic kidney disease, anemia, and osteoarthritis of right knee. R1's MDS (Minimum Data Set) dated 06/16/2025, documented that R1 has a BIMS (Brief Interview for Mental Status) score of 15 indicating R1 is cognitively intact. R1's Care Plan with a revision date of 09/30/2024 has a focus are of The resident has chronic pain. Interventions listed are administer analgesia as per orders, anticipate the resident's need for pain relief and respond to any complaint of pain, monitor/record/report to nurse any signs and symptoms of non - verbal pain,…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-06-03 · tag F0580 — failed to tell family and doctor about changes — isolated
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify a resident's representative of a hospital admission for 1 (R1) of 3 residents reviewed for notification of changes in the sample of 8. Findings include: R1's admission Record documents an admission date of 03/06/25 and includes diagnoses of encounter for orthopedic aftercare following surgical amputation, type 2 diabetes mellitus with diabetic neuropathy, unspecified; unspecified severe protein-calorie malnutrition; osteomyelitis, unspecified; local infection of the skin and subcutaneous tissue. R1's Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 6, indicating that R1 has severe cognitive impairment. On 06/03/25 at 10:24am, V2 (Director of Nursing/DON) stated R1 had an appointment with Podiatry on 05/29/25 and they scheduled him for a debridement the next morning. V2 stated they were waiting on the preauthorization for R1's procedure. V2 stated on 05/30/25 when they took R1 to the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2025-05-14 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide sanitary food service by not performing hand hygiene. This failure has the potential to affect all 64 residents residing at the facility. Findings include: 1. On 05/05/25 at 12:35 PM, V17 (Certified Nurse Aide/CNA) transferred glasses onto several residents' lunch trays by the rim area where the resident would drink from after touching the wheelchair handles of two wheelchairs and her scrub top with no hand hygiene in between. On 05/06/25 at 12:03 PM, throughout lunch service V4 (CNA) transferred glasses onto several residents' lunch trays by the rim area where the resident would drink from after touching the wheelchair handles of two wheelchairs and her scrub top with no hand hygiene in between. On 05/06/25 at 12:07 PM, throughout lunch service V5 (Housekeeping Supervisor) transferred glasses onto several residents' lunch trays by the rim area where the resident would drink from after touching the dietary cart door, the handles of…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-05-14 · tag F0550 — failed to protect resident dignity and rights — pattern
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to answer call lights timely and promote resident dignity during dining for 4 (R6, R19, R22, and R25) of 4 residents reviewed for resident rights in the sample of 46. Findings Include: 1. R25's admission Record documented an admission date of 5/5/2023 with diagnoses that included hemiplegia affecting left non dominant side, peripheral vascular disease and generalized anxiety among others. R25's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status score of 15, indicating R25 is cognitively intact. R25's MDS also documented he was dependent on staff for toileting, showering, dressing and transferring. On 5/6/2025 at 8:15AM, R25's call light was noted to already be activated. R25's call light remained activated until staff answered the call light at 9:00AM. At 9:05AM, R25 said he had activated his call light at 7:00AM and the staff did not respond until two hours later at 9:00AM. 2. R19's admission…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-05-14 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
  Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation and interview, the facility failed to provide a clean and homelike environment for 2 (R49 and R54) of 4 residents reviewed for environment in a sample of 46. Findings include: On 5/6/25 at 9:20AM, a feces soiled bedpan was seen sitting in the bathtub of R54 and R49's shared bathroom. On 5/6/25 9:20AM, R54 was alert and oriented and stated he knew the staff stored his bedpan in the bathtub, but did not know they were not cleaning it before storing it. On 5/6/25 at 2:49PM, the same soiled bedpan was noted to be in R54 and R49's shared bathtub. On 5/7/25 at 8:15AM, the same soiled bedpan was noted to be sitting in R54's and R49's bathtub. On 5/7/25 at 11:30AM, the same soiled bedpan was noted to still be sitting in R54's and R49's bathtub. On 5/7/2025 at 11:30AM, R49 was alert and oriented and stated he was not aware of a soiled bed pan being left in the bathtub in his bathroom. R49 said he was upset by the soiled bedpan causing a foul odor in his room and asked the staff to remove it. On 5/7/25 at 11:45AM, V9 (Housekeeper) said a soiled bed pan should not be left…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-05-14 · tag F0658 — failed to meet professional standards of care — isolated
  Ensure services provided by the nursing facility meet professional standards of quality.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure that services were provided within the professional scope of practice when nursing staff administered and documented multiple medications late to 3 (R8, R23, and R37) of 5 residents reviewed for medication administration in a sample of 46. Findings include: 1. R23's admission Record documented an admission date of 09/29/2022 and included diagnoses of type 2 diabetes mellitus with diabetic neuropathy and depression. R23's Minimum Data Set (MDS) assessment dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 15, indicating R23 is cognitively intact. R23's Medication Admin Audit Report documents the following physician's orders: Desmopressin Acetate Tablet 0.1 MG (milligram), Give 1 tablet by mouth at bedtime, with a schedule date of 05/05/25 at 8pm, an administration time of 8:32pm, and a documentation time of 2:34am on 05/06/25, which was documented by V13 (Licensed Practical Nurse/LPN). Desmopressin Acetate Tablet 0.2 MG,…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-05-14 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
  Provide care and assistance to perform activities of daily living for any resident who is unable.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to ensure residents were assisted with activities of daily living (ADL's) in a timely manner for 3 (R6, R7, and R24) of 19 residents reviewed for ADL assistance in a sample of 46. Findings include: 1. R7's admission Record documents an admission date of 05/27/2020 with diagnoses that included type 2 diabetes mellitus, dementia, unspecified psychosis not due to a substance or known physiological condition, chronic kidney disease, and history of transient ischemic attack and cerebral infarction. R7s Minimum Data Set (MDS) assessment dated [DATE] documents no Brief Interview for Mental Status (BIMS) score was conducted due to resident is rarely/never understood. Under the section for Functional Abilities and Goals, the MDS documented R7 needed supervision or touching assistance for eating, indicating helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-05-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement new interventions to prevent falls for 2 (R27 and R63) of 4 residents reviewed for accidents/supervision in the sample of 46. The Findings include: 1. R27's admission record dated 05/08/25 documents an admission date of 07/22/22 with diagnoses in part of lack of coordination, abnormal posture, unsteadiness on feet, disorder of bone density and structure, and repeated falls. R27's Minimum Data Set (MDS) dated [DATE] documents under Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 15, indicating R27 is cognitively intact. Under Functional Abilities and Goals, the MDS documents R27 needs supervision or touching assist with toileting and walking. A facility Initial Incident report in the electronic health record dated 04/28/25 documents R27 experienced a fall. This document includes a progress note of the incident that states: in part of CNA (Certified Nurse Assistant) called this nurse to hall et stated resident was…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

$435,072 in federal fines across 3 penalties. 1 Medicare payment denial on record.

• $258,555 — penalty dated 2025-11-14
• $10,839 — penalty dated 2024-04-02
• $165,678 — penalty dated 2024-04-02
• Medicare payment denial — starting 2024-04-27 for 48 days

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to CREST HEALTHCARE CONSULTING — 11 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

CMS files one row per role, so the 24 rows in the source record cover these 14 parties — each is shown once here with every role it holds. Nothing is omitted.

8 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

About 72% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.2M paid to related parties — landlords or management companies under common ownership — equal to about 14% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in IL